USTEPS and UPI Access Forms

• 0-1 DSPD Employee USTEPS ACCESS Form
• 0-2 USTEPS Support Coordinator Contracted Provider Access Request Form
• 0-3 Individual User Email Change Request Form
• 0-5 Private Support Coordinator Company Access Request Form
• 0-8 USTEPS Provider Interface (UPI) Individual User Access Form
• 0-9 USTEPS Provider Interface (UPI) Provider Company Designee Access Form
• 0-10 Provider Company Email Change Request Form

Deceased Client Report Form

• 5-2 Deceased Client Report Form

Invitation to Submit Offer to Provide Services Forms

• 1-6 Invitation to Submit Offer to Provide Services (PDF)
• 1-6 Invitation to Submit Offer to Provide Services (Word Version)

Division and Department Codes of Conduct:

• Division of Services for People with Disabilities Code of Conduct
• Department of Human Services Code of Conduct
• 5-3 Code of Conduct Certification

Supported Work Independence Program:

• 201 Supported Work Independence Client Information Form
• 202 Supported Work Independence Participation Agreement
• 203 Community Services Brokering Action Plan

Miscellaneous Forms

• Certified Provider Background Screening Application
• Youth Background Screening Application
• Certified Provider Background Screening Application Instructions
• DHS Conflict of Interest – Declaration Form
• 1-2 Authorization to Furnish Information and Release from Liability
• 1-2A Release of Information
• 1-3 Voluntary Financial Support Agreement
• 1-18 Request to Amend or Add to Record
• 1-19 Evaluation for ESMC Waiting List One-Time Funded Services
• 101 In-Home Treatment Exception Request – Medicaid Autism Waiver
• 295 CAPS Form – One-Time Payment Form
• One Time Payment Process
• 295A One-Time Payment Process Pre Purchase Assessment
• 520 Provider Service Invoice
• 801 PASRR Categorical Determination
• 802 PASRR Individualized Determination
• 902 Physical Examination Report
• 928 Exceptional Needs Prior Authorization for Residential Habilitation
• 929 Respite – Intensive Screening
• 930 Enhanced Supervision & Rate Form
• 930a Guidelines for Enhanced Staffing & Rates
• ICF/ID Transition Fact Sheet